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Diagnosis Codes

Diagnosis codes are also known as ICD-10 (International Statistical Classification of Diseases and Related Health Problems, Version 9) codes (formerly ICD-9). These codes are used to describe illnesses or injuries, and their severity without having to always write everything out. This was a major change from ICD-9 in that ICD-9 had 16,000 codes whereas ICD-10 has 111,000.

Every medical claim submitted to insurance for payment has to include a diagnosis code, and that diagnosis code has to be related in to the treatment you're receiving. Diagnosis codes begin with a letter, then 2 numbers. After the period there can be as many as 4 other characters. The idea was to make them more definitive than they were previously.

Here's an example of what a coder might see now:

  •  F40.24 Situational type phobia
  •    F40.240 Claustrophobia
  •    F40.241 Acrophobia
  •    F40.242 Fear of bridges
  •    F40.243 Fear of flying
  •    F40.248 Other situational type phobia

Insurance companies can deny coverage of procedures if the diagnosis codes are either incorrect or not definitive enough. In some instances, you might be required to sign off on an advanced beneficiary notice if your medical practitioner knows your procedure won't be covered.

In other circumstances, diagnosis codes might be needed in order to get an approval or authorization from your insurance company. Once again, the diagnosis code and procedure codes must match up to get approval for the procedure. However, sometimes even this isn't enough.

A patient's account can have multiple diagnosis codes, and probably should have them. Physicians are notorious for not putting down all the diagnosis codes which may apply to your condition, which is a very common reason why some services may be denied. If you find this happening, a good place to check would either be your physician's office or the hospital's medical records office, because, unfortunately, hospital medical records will sometimes code an account incorrectly, and, as it applies to some outpatient services, will use the code a physician sent rather than changing it because the physician's word is supposed to be golden. A good medical records department will contact the physician's office when they see something blatantly incorrect, but not always.

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